Inspection·December 6, 2023

F 0686 Upon admission to the facility a nursing progress note, dated [DATE] at 3:30 P.M. indicated the resident had multiple skin issues noted. No additional information was provided. Level of Harm - Actual harm Residents Affected - Few Review of the electronic health record (EHR) revealed no evidence of a wound assessment completed at the time of admission on [DATE]. Review of Resident #95 skin breakdown assessment tool dated [DATE] indicated the resident was at high risk for development of skin breakdown and had current areas of skin breakdown. Review of the admission care plan dated [DATE] revealed wounds were present on admission, see wound notes. Interventions: encourage to turn/reposition every two hours, check skin daily with care and bathing weekly, report changes to the nurse/nurse practitioner/physician, obtain and place pressure redistribution devices as indicated, record wound measurements weekly, inform the nurse practitioner/physician of any changes in skin condition, monitor for pain, educate on disease management as needed. Further review of Resident #95's medical record revealed following admission to the facility there was no evidence of wound care orders or preventative interventions being implemented to assist in wound healing and further skin breakdown except skin prep (protects skin from friction) to bilateral heels every shift, ordered [DATE]. Review of Resident #95's admission history and physical on [DATE] completed by the facility Medical Director revealed Resident #95 had significant pressure ulcers of the sacrum and recommended to follow up with wound care team, dressings and rotation. However, there was no evidence of orders for wound care or preventative measures. Review of Resident #95's Minimum Data Set (MDS) 3.0 admission assessment with a reference date of [DATE] revealed the resident required extensive assistance to total dependence for all activities of daily living (ADL) including bed mobility, transfers, dressing, hygiene, toileting and bathing. The resident was identified as being at risk for pressure ulcer development. The MDS identified Resident #95 had no current unhealed pressure ulcers. Review of the weekly wound assessments revealed no evidence of wound assessments upon admission until [DATE] when Resident #95 was evaluated by the facility wound nurse practitioner consultant and additional pressure wounds were identified. Review of the Treatment Administration Records (TAR) for Resident #95 revealed no evidence of any wound care from admission until [DATE] after the resident was seen by the wound care nurse. Review of a wound nurse consultant evaluation on [DATE] revealed the following areas of skin breakdown were identified for Resident #95: an unstageable (slough or eschar, known but unstageable due to coverage of wound bed by slough or eschar) pressure ulcer to the coccyx/sacrum measuring 15.0 cm by 19.0 cm, a left heel DTI measuring 9.5 cm by 13.5 cm, a left lateral foot DTI measuring 1.5 cm by 2.0 cm, a left fifth lateral metatarsal DTI measuring 1.3 cm by 2.0 cm, a left lateral malleolus DTI measuring 3.0 cm by 2.2 cm, a left first metatarsal head DTI measuring 1.8 cm by 2.2 cm, a left great metatarsal DTI measuring 0.5 cm by 1.5 cm, a right heel DTI measuring 5.5 cm by 8.0 cm and an ulcer to the right lateral calf assessed to be a DTI measuring 6.5 cm by 5.5 cm. New orders were given for a low air loss mattress to the bed, protein supplements twice a day and oxy ears (padding for oxygen tubing at the ears) for prevention. Nursing was to wash the unstageable pressure ulcer to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Navarre Ctr for Rehab & Nrsg Care 517 Park Street NW Navarre, OH 44662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm sacrum/coccyx with wound cleanser and apply Triad (adheres to wet [NAME] and can be used on broken skin in the presence of incontinence or maceration of the peri-wound) three times a day and as needed. The remaining ulcers nursing was to apply skin prep, ABD (non-woven dressing that is thick and absorbent) and wrap with kerlix (gauze wrap) daily. Residents Affected - Few Review of the facility wound assessments also completed on [DATE] revealed no evidence of a comprehensive wound assessment for the pressure ulcer to the left heel as identified by wound nurse practitioner consultant. Further review of the physician orders revealed the addition of low air loss mattress dated [DATE], ProSource (protein supplement) 30 milliliters twice a day written [DATE], and only to be up in chair for therapy dated [DATE]. Review of the wound nurse consultant evaluation on [DATE] revealed the resident was assessed to have the following pressure ulcers: a new pressure ulcer wound to the left calf that was assessed to be unstageable measuring 15.0 cm by 3.5 cm, a coccyx/sacrum unstageable pressure ulcer measuring 15.0 cm by 19.0 cm, a left heel DTI measuring 6.7 cm by 12.0 cm, a left lateral foot DTI measuring 1.3 cm by 1.9 cm, a left fifth metatarsal DTI measuring 0.9 cm by 1.7 cm, a left lateral malleolus pressure ulcer measuring 3.0 cm by 2.2 cm, a left first metatarsal head DTI measuring 1.8 cm by 1.9 cm, a left great metatarsal DTI measuring 0.5 cm by 1.5 cm, a right heel DTI measuring 5.5 cm by 6.0 cm, and a right lateral calf unstageable measuring 11.0 cm by 6.6 cm. Review of the facility wound assessments also completed on [DATE] revealed no evidence a wound assessment was completed for the ulcers to the coccyx/sacrum, left heel or left calf wounds and there was no description or staging for the ulcers to the left lateral foot, left lateral malleolus and left fifth metatarsal. Review of the progress note dated [DATE] at 2:08 P.M. revealed the patient has been confused, shaky and is running a fever of 101.8 (degrees Fahrenheit). The Nurse Practitioner (NP) was notified, and she ordered Tylenol 650 (milligrams) every six hours as needed. I administered the Tylenol at 2:05 P.M. to the patient. The patient was unpleasant not wanting to take the Tylenol. The patient ended up taking the Tylenol. He is resting in bed with his CPAP on and his wife at the bedside. Review of the progress note dated [DATE] at 8:24 P.M. revealed this nurse went to assess the resident at the beginning of her shift. Vitals blood pressure 108/53, temp 99.3 oral, pulse 126 respirations 26 and pulse ox (oxygen level) 90 (%) on four liters (of oxygen) via nasal cannula (normal 92-100%). Resident was exhibiting signs of rapid breathing, was very lethargic. Nurse Practitioner notified and explained the situation to her. Ordered a STAT (immediate) chest x-ray. Nurse Practitioner ordered to send resident to the hospital if oxygen level of 90 (%) not achieved. Resident's wife wanted resident sent to the hospital. Resident sent to (hospital name) for further evaluation. Review of the progress note dated [DATE] at 9:52 P.M. revealed update from (hospital name). Resident admitted with sepsis, urinary tract infection (UTI), ulcer and confusion. Review of the hospital records revealed a consult note dated [DATE] (unknown department) revealed the resident was an uncontrolled diabetic, obese. History of vascular reconstruction and amputation of one toe. Large pressure ulcer on the sacral area which extends from the sacral (area) to both buttocks as a large butterfly type ulcer, black necrotic very hard leather like, still adherent to the underlying tissues and is not separated. Measures 12 (cm) by 15 (cm) in size. No additional notes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Navarre Ctr for Rehab & Nrsg Care 517 Park Street NW Navarre, OH 44662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 were in the hospital record. Level of Harm - Actual harm Further review of the hospital record revealed the resident remained hospitalized from [DATE]-[DATE] when he transferred to a skilled care facility and then to another long-term care facility on [DATE]. Residents Affected - Few Interview with Registered Nurse (RN) #105 on [DATE] at 2:30 P.M. verified there were no wound care orders implemented following admission ([DATE]) until [DATE], no evidence of preventive skin interventions being implemented following admission for the resident, who was identified to have skin impairment on admission and additional risk for the development and/or worsening of current pressure wounds, an error on the MDS coding related to staff documenting the resident had no current pressure ulcers (the resident did have pressure wounds/ulcers at the time of the assessment) and errors in facility wound assessments completed on [DATE] and [DATE]. During a follow up interview with RN #105 on [DATE] at 9:30 A.M. the RN verified upon admission Resident #95 did not have a formal wound assessment completed in the EHR to identify current skin issues including wound staging, description and measurement. RN #105 indicated the admission nurse was to complete the paper admission skin assessment, then forward a copy of the admission skin assessment to the facility wound nurse for completion of the formal wound assessment. Attempts were made to reach Resident #95's spouse; however, the attempts were unsuccessful. This deficiency represents non-compliance investigated under Complaint Number OH00148601. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365482 If continuation sheet Page 4 of 4